Foramen secundum

The ostium secundum (or foramen secundum) is a foramen in the septum primum.

It should not be confused with the foramen ovale, which is a foramen in the septum secundum.

Discovery

The discovery of the formation of the foramen secundum and septum secundum were published by P. N. B. Odgers at the University of Oxford in the Journal of Anatomy in 1935.^[1]

Embryological development

During development, the atria initially share a common chamber. As the two begin to separate, the septum is not fully formed to allow blood shunting from the right to left atrium in order for blood to bypass the lungs. The septum primum and spina vestibuli grow together to divide the right and left atria during the fifth week of development. This results in the formation of the foramen primum. The septum primum will continue to grow until the sixth week when the dorsal and ventral cushions will fuse to form the atrioventricular septum. The fusion process closes the foramen primum via controlled cell death (apoptosis) and several smaller perforations come together to form the foramen secundum. The perforations form before the foramen primum closes completely, ensuring the shunting process continues at all stages.^[2]

Anatomical position

Blood, shown in the red arrow, travels through the foramen ovale and the foramen secundum. HH: right ventricle, VH: left ventricle, HF: right atrium, VF: left atrium, LV: pulmonary vein

The septum primum is found on the left side of the heart in the left atrium while the septum secundum is much thicker and found on the right side in the right atrium. During development, blood shunts from the floor of the right atrium through the foramen ovale in the septum secundum then up through the foramen secundum in the septum primum.^[3] The foramen secundum is positioned so that blood exits in the ceiling of the left atria and then out through the left ventricle and the aorta. The position of the foramen secundum, as well as the size of the septum primum, are crucial to ensuring blood does not flow backwards from the left atrium to the right atrium. The septum primum, being much thinner, is easily pressed against the septum secundum if blood attempts to flow in the reverse direction, effectively sealing off both the foramen secundum and the foramen ovale.^[2]

Closing during birth

To provide proper blood flow as a newborn, the foramen secundum and foramen ovale must close when birth occurs. Since the lungs now require a significant amount of blood flow, the vessels going to and from the lungs undergo dilation. While the pulmonary artery and pulmonary veins are dilating, the umbilical artery and umbilical vein are severed due to the cutting of the umbilical cord, or the funiculus umbilicalis. This combination results in a reversal of pressure differences between the atria and the septum primum is permanently forced against the septum secundum. This holds true even during atrial diastole, when the pressure is significantly less than atrial systole.^[2]

Clinical significance

An ostium secundum that persists at large size can be a source of atrial septal defects.^[4] Ostium Secundum atrial septal defects are the most common atrial septal defects. This defect can arise as a result of defects of the septum primium and the septum secundum. For the septum primium, the problem can arise as a result of excess resorption of the septum during the process of apoptosis in order to form the foramen secundum. For the septum secundum, inadequate growth of it can cause atrial septal defect since it is supposed to grow and eventually overlap the foramen secundum so as to form the oval foramen.

Treatment of ostium secundum atrial septal defects

Newborns with small foramen secundum atrial septal defects have been shown to spontaneously correct by the third or fourth year of life.^[5] Therefore, medical supervision is generally accepted as a preventative measure for those diagnosed in infancy rather than surgical intervention or use of other medical devices.^[6]

If surgery is required, it is performed using minimally invasive techniques via robotic surgery that often requires only two to three days of inpatient hospital stay.^[7] Surgical intervention should result in full closure of the foramen secundum and mortality rates are similar to those for general anesthesia.^[8] The repair can be made by suturing the atrial septum or, if the foramen secundum is large in size, a patch can be made from the patient's pericardium to fully separate each atria. The synthetic material Dacron is also used to create a repair patch.^[9]

The insertion of a catheter has proven to be a safe and highly successful method for closing the foramen secundum in children.^[10] This method prevents the symptoms that are expected to accompany most ostium secundum atrial septal defects. The catheter is inserted into the femoral vein in the leg and moved into place in the atrial septum. Transesophageal echocardiography is accepted as the method to monitor this procedure which, when performed correctly, has shorter recovery times than surgical intervention.^[11] Complications of catheter insertion often include nausea and vomiting, blood vessel obstruction, pain, and hemorrhage. The most common problem with this preventative measure is the incomplete closing of the foramen secundum.^[12] There are currently no drug therapies for ostium secundum atrial septal defects, although infective endocarditis is a postoperative concern. To prevent this condition, a prophylactic is used for six months after the operation.^[13]

Prognosis

Many patients with an ostium secundum that persists into adulthood will remain asymptomatic the duration of their lives. A mortality rate of less than one tenth of one percent is expected if the operation is performed correctly. Some argue that if the operation takes place before eight years of age, cardiac abnormalities such as cardiac dysrhythmia will be severely limited later in life.^[14] Others argue that the operation can take place as late as twenty four to limit cardiac complications after age forty. Mitral regurgitation and mitral valve prolapse are common after the age of forty if the ostium secundum is not repaired by age twenty four, according to some sources.^[15] Operative closure of atrial septal defects after the age of forty and the ability to diminish symptoms at all remains controversial. Some data does suggest that even after the age of forty, symptoms can be alleviated via surgical intervention, including prevention of Arrhythmogenic right ventricular dysplasia and other associated cardiac abnormalities.^[16]

References

1. ↑ Anatomical Society of Great Britain and Ireland. J Anat. 1935 July; 69 (Pt 4): 412–422.5
2. ↑ 2.0 2.1 2.2 Schoenwolf, Gary C., and William J. Larsen. Larsen's Human Embryology. 4th ed. Philadelphia: Churchill Livingstone/Elsevier, 2009. 363. Print.
3. ↑ "Understanding Patent Foramen Ovale (PFO)." Understanding Patent Foramen Ovale. St, Jude Medical, n.d. Web. 27 Nov. 2012.
4. ↑ ped/1686 at eMedicine
5. ↑ Hanslik A, Pospisil U, Salzer-Muhar U, Greber-Platzer S, Male C. Predictors of spontaneous closure of isolated secundum atrial septal defect in children: a longitudinal study. Pediatrics. Oct 2006;118(4):1560-5
6. ↑ Rigatelli G, Dell' Avvocata F, Cardaioli P, Giordan M, Vassiliev D, Nghia NT, et al. Five-year Follow-up of Intracardiac Echocardiography-assisted Transcatheter Closure of Complex Ostium Secundum Atrial Septal Defect. Congenit Heart Dis. Oct 20 2011
7. ↑ Argenziano M, Oz MC, Kohmoto T, et al. Totally endoscopic atrial septal defect repair with robotic assistance. Circulation. Sep 9 2003;108 Suppl 1:II191-4.
8. ↑ Bolz D, Lacina T, Buser P, et al. Long-term outcome after surgical closure of atrial septal defect in childhood with extensive assessment including MRI measurement of the ventricles. Pediatr Cardiol. Sep-Oct 2005;26(5):614-21
9. ↑ Shah D, Azhar M, Oakley CM, et al. Natural history of secundum atrial septal defect in adults after medical or surgical treatment: a historical prospective study. Br Heart J. Mar 1994;71(3):224-7
10. ↑ Jones TK, Latson LA, Zahn E, et al. Results of the U.S. multicenter pivotal study of the HELEX septal occluder for percutaneous closure of secundum atrial septal defects. J Am Coll Cardiol. Jun 5 2007;49(22):2215-21.
11. ↑ Post MC, Suttorp MJ, Jaarsma W, Plokker HW. Comparison of outcome and complications using different types of devices for percutaneous closure of a secundum atrial septal defect in adults: a single-center experience. Catheter Cardiovasc Interv. Mar 2006;67(3):438-43.
12. ↑ Butera G, Carminati M, Chessa M, et al. Percutaneous versus surgical closure of secundum atrial septal defect: comparison of early results and complications. Am Heart J. Jan 2006;151(1):228-34
13. ↑ Gessner MD, Neish MD, et al. Ostium Secundum Atrial Septal Defects Medication. Medscape Reference. Dec 1, 2011.
14. ↑ Brochu MC, Baril JF, Dore A, et al. Improvement in exercise capacity in asymptomatic and mildly symptomatic adults after atrial septal defect percutaneous closure. Circulation. Oct 1 2002;106(14):1821-6.
15. ↑ Groundstroem, et al. Late postoperative follow-up of ostium secundum defect. European Heart Journal (1999). 20, 904-909
16. ↑ M. Jemielity, W. Dyszkiewicz, et al. Do patients over 40 years of age benefit from surgical closure of atrial septal defects? 1 September 2000. Heart 2001; 85: 300-303

External links

• Embryology at Temple Heart98/heart97a/sld036
• http://www.mayoclinic.org/atrial-septal-defect/types.html
• http://sprojects.mmi.mcgill.ca/embryology/cvs/ias.html
• http://staff.um.edu.mt/acus1/Heart-b.htm